Quality Account 2019/20 PG2 - Amazon Web Services...SSKIN is a five-step model for pressure ulcer...

Quality Account 2019/20 PG2

INDEX Part 1 – Statements 1.1 Statement of the Chairman of the Board and Chief Executive

4

Part 2 – Priorities for Improvements and Statements of Assurance 2.1 Priorities for Improvements 2019-2020 (what we achieved last year)

Priority 1 - Patient Safety - Incident and Accident Reporting & Learning

Priority 2 - Clinical Effectiveness - OACC (Patient Feedback) CQUINN

Priority 3 - Patient Experience - Breathlessness Clinic 2.2 Other Hospice achievements 2019 - 2020 2.3 Priorities for Improvements 2020 - 2021

Priority 1 - Patient Safety - Improved Clinical Governance processes

Priority 2 - Clinical Effectiveness – A Joint Hospice and End of Life Service

Priority 3 - Patient Experience - Patient feedback of HoBs 2.4 Statement of assurance from the Board

Birmingham St Mary’s Hospice: A research engaged and generating hospice

Education: What we have done this year to educate our staff & other healthcare professionals

Guideline development and review

Use of CQUIN payment framework 2018-19

Data Quality

Information Governance toolkit

Clinical coding error rate

Duty of Candour

Part 3 – Review of quality of performance 3.1 Clinical Data

In-Patient Unit

Community Palliative Care Team

Day Hospice

Hospice at Home

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28

29

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3.2 Quality Markers

Patient Slips, Trips and Falls

Pressure Ulcers

Medicines Management

Compliments and Complaints 3.3 Clinical Audit 3.4 Feedback from patients and families on services

3.5 Benchmarking Activity 3.6 Statements on Birmingham St Mary's Hospice Quality Account for 2019-20 NHS Birmingham and Solihull Clinical Commissioning Group (CCG) 3.7 Feedback and Comments

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38

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ABBREVIATIONS

CGC Clinical Governance Committee (part of the Hospice’s governance framework)

CQUIN Commissioning for Quality and Innovation (payment)

DTI Deep Tissue Injury

IPOS Integrated Palliative Care Outcome Scale

IPU In-Patient Unit

MHRA Medicines and Healthcare Products Regulatory Agency

NICE National Institute for Health and Care Excellence

NIHR National Institute for Health Research

OACC Outcome Assessment and Complexity Collaborative


WHAT IS A QUALITY ACCOUNT?

Patients want to know they are receiving the very best quality of care. A Quality Account is a report about the quality of services by an NHS provider/funded service, and each year all NHS providers/funded services are required to publish a Quality Account. These are required by the Health Act 2009, and in the terms set out in the National Health Service (Quality Accounts) Regulations 2010 as amended1 (‘the Quality Accounts regulations’). Information on quality accounts can be found on the NHS Choices website. The report is an essential way for local services to publish information on the quality of care it provides and to demonstrate improvements and developments in its services. The report enables local communities and stakeholders to review the progress that the Hospice is making in delivering its Quality Priorities and to hold the provider to account. Birmingham St Mary’s Hospice is committed to continuously improving the services it provides to patients and their families. Within the Quality Account, we aim to make the following information available to stakeholders, patients and the public. • Our Quality Priorities for the year 2020/21 • Our progress against delivery of the Quality Priorities we outlined in 2019/20 • How we have performed against national quality indicators for patient safety, patient experience

and clinical effectiveness • How we have performed against local quality measures as agreed with our commissioners • How we will ensure that Birmingham St Mary’s Hospice maintains continuous quality

improvement


Part 1 – Statements

1.1 Statement from the Chairman of the Board of Trustees and Chief Executive At Birmingham St Mary’s Hospice, individuals, their families, carers and loved ones come first.

I am delighted to present this Quality Account for Birmingham Saint Mary's Hospice to reflect the quality of our services over the last twelve months. This Quality Account is for our patients, their families and friends, the general public as well as the local NHS organisations that we work with across Birmingham and Solihull. This report aims to give clear information about the quality of our services to help the public, patients and other stakeholders understand what we're doing well, where improvements in service quality are required and what our priorities for improvement during the coming year are. It covers how we are assured about the quality of care provided by the Hospice as well as outlining the key quality improvements delivered in 2019/20.

I am pleased to report that we have made strong progress in delivering against our Quality Account priorities for 2019/20: We have seen growth in the development of our children's services with additional staff providing emotional support to children and their families both pre and post bereavement thanks to funding received from Children in Need. We also improved our responsiveness to referrals for our care by implementing a system of contacting all urgent referrals within 24 hours and routine referrals within 48 hours of receipt with all patients being offered a clinic or a home visit whichever is convenient for them. We have also further integrated our Clinical Nurse Specialist (CNS) and Hospice at Home teams during the year and most recently have worked with John Taylor and Marie Curie Hospices to provide a 24-hour rapid response service across the city during the Covid-19 pandemic. Within the Hospice, we have improved our efficiency with the introduction of new IT systems, including an electronic reporting system for incidents and risks and a new HR/payroll system to streamline workforce processes. Our staff's wellbeing is of utmost importance to us, and during the year, we have trained and launched 19 Mental Health First Aiders to support the wellbeing of staff across all areas of the Hospice. We also held a Wellbeing Day to coincide with Mental Health Awareness Week and held several resilience workshops to give staff a range of tools they can access to help with their resilience. Following a recent unannounced CQC inspection in September 2019, the Hospice was rated as ‘Good’ and echoes the progress we have made – in quality, patient satisfaction, staffing and continuous improvement. We know that we could not give such high standards of care without our hardworking staff and volunteers, and I would like to take this opportunity to thank them all for their hard work over the last twelve months. This year’s Quality Account has been prepared by Ameer Chughtai, Clinical Governance Manager with support from our clinical teams and to the best of my knowledge, the information reported in this document is accurate and a fair representation of the quality of healthcare services provided by Birmingham St Mary’s Hospice.

Penny Venables Chief Executive


Niels de Vos Chair

(Stepped down March 2020)

Harry Turner, JP

Chair (Appointed March

2020)

Mike Russell Vice-Chairman

& Honorary Treasurer

(Retired October 2019)

Stan Leyland Trustee

(Retired October 2019)

Denise McLellan Trustee

Gurinder Mandla Trustee

Karen Dowman Trustee

Andrew Williams Trustee

Dr Sabena Jameel Trustee

Colin Graham Trustee

Salma Ali Trustee

Jonathan Crawford Trustee

Sharon Benton Trustee

(Stepped down March 2020)

Dr Ken Deacon Trustee

Simon Jarvis Trustee


The Executive Team are responsible for ensuring the Hospice Strategy is delivered as well as making sure the day to day operational aspects of the Hospice are maintained. The Associate Directors support the Executive Team in this delivery: EXECUTIVE DIRECTORS

Tina Swani

Chief Executive (Left post May 2020)

Penny Venables Chief Executive

(Appointed May 2020)

Lynsey Breeze Finance Director

(Maternity leave from August

2019)

Dr Debbie Talbot Medical Director

Helen O’Halloran

Nursing Director

Hillary Barrett Director of

Income Generation &

Marketing (Interim – left post

January 2020)

Emma Bryan Interim Finance Director (Interim)

Lucy Watkins Director of

Income Generation

(Started in post January 2020)

ASSOCIATE DIRECTORS

Lucy Chatwin

Head of Support Services (Left post

11/06/2019)

Trish Squire Head of Service

Improvement and Quality

(Left post 04/05/2019)

Christina Radcliffe

Consultant in Palliative Medicine

Esther Reilly Deputy Nursing

Director (Started in post

29/07/2019)

Garry Barr Head of

Corporate Services

(Started in post 27/08/2019)


1.2 Our Hospice Strategy 2016 – 2020 - “Hospice Care for All”

Birmingham St Mary's Hospice offers a range of services in a number of settings. We welcome individuals, families, partners and carers from our diverse population across Birmingham and Sandwell. Our care is provided in people's homes, or community locations close by, in addition to progressive inpatient and day services at the Hospice. Over the past year since the launch of our strategy, we have significantly increased the number of people we support. This includes; 1,747 individuals receiving palliative care, support to 419 family members, bereavement support for 368 individuals and 41 children who have experienced the loss of a family member. We want to continue to significantly improve the experience of living with a terminal illness for a lot more people. As a teaching Hospice, we work alongside other health and social care professionals in prison services, care homes, hospitals, community and mental health services. Our education programmes extend to this vast network of care providers, including GPs and District Nurses so that, together, we can strive to reach more people and achieve "Hospice Care for All"

Our Vision, Values and Priorities Our Vision A future where the best experience of living is available to everyone leading up to and at the end of life. Our Values

Delivering quality care

Improving access for all

Sharing expertise

Working collaboratively

Changing attitude

Our Priorities 1. Providing a better experience at the end of life 2. Expanding our specialist centre of research and

learning 3. Locating our facilities so we can reach more

people 4. Being an employer and volunteering centre of

choice 5. Achieving growth, influence and financial stability

This Quality Account illustrates, through specific examples, our commitment to continual improvement to service quality and through innovation.


Part 2 – Priorities for Improvements and Statements of Assurance

2.1 Priorities for improvement 2019-20 - what we achieved last year

How was it identified as a priority? Incident reporting across the Hospice had significantly grown over the last few years. This increase can be due to several factors, including but not limited to:

Open reporting culture Increased data capture requirements for CCGs Health range of patients we are caring for Increased staff knowledge of Incident and Risk Identification

The Incident and Accident form was paper-based. Updated in 2012 and again in 2016, the incident reporting form was developed as a ‘capture all’ form, for both clinical and non-clinical incidents. Additionally reporting forms had been created to support the reporting of Pressure Ulcers and Drug Incidents.

Despite procedures in place, the physical movement of incident forms once completed had its challenges. The current system had become insufficient and delayed the responsiveness of reporting incidents when they immediately happened. Subsequently, a more robust incident reporting system was required, and the implementation of Datix electronic incident reporting system will mitigate historic risks going forward, ensuring incidents are reported in a timely, user-friendly and intuitive manner. How was the Priority achieved? Through the implementation of Datix electronic incident reporting system for the Hospice, this has enabled incidents to be reported promptly once identified and give ownership for staff to communicate and manage incidents effectively. The implementation of Datix has achieved the Priority. It will ensure the Hospice has one of the leading pioneers of incidents reporting software systems to utilise for incident reporting and management, providing lessons are learnt from adverse/unexpected events. How was progress monitored and reported? Incident reporting was monitored and continue to receive robust scrutiny at each of the Governance Committees as applicable and will receive regular updates of the effectiveness via Datix. Monthly reports looking into the efficacy of timely reporting will be monitored at both the Clinical Quality Sub Group meeting and Clinical Governance meeting.

Patient Safety Priority: Incident, Accident reporting and learning Standard: To develop and implement an electronic Incident Reporting System across

the Hospice, which is accessible to all staff regardless of working location


How was it identified as a priority? Health services and health care professionals are required to demonstrate that they meet the needs of individual patients and their families and that they do this effectively and efficiently.

To achieve this, and to strive towards higher standards of care, services and staff must be able to show that they are making a measurable and positive difference to patients and families receiving their care. The Outcome Assessment and Complexity Collaborative (OACC) has collated a suite of fit-for-purpose measures designed to capture and demonstrate this difference for palliative care services.

The Outcome Assessment and Complexity Collaborative (OACC) measures can be used to improve team working, drive quality improvement, deliver evidence on the impact of services, inform commissioning and, most importantly, achieve better results for patients and families. How was the Priority achieved? Feedback from the clinical leaders has been gathered, and this has contributed to the CQUIN report produced. The CQUIN Lead has met with representatives of the teams involved with the implementation of OACC measures either individually or at team meetings. Understanding some of the barriers to using the various tools has been reached and has been supported by introducing new processes and working patterns to capture data. Ongoing training and support have been provided to teams and individuals when required. How was progress monitored and reported? The Priority was achieved through regular contact with the leads for the clinical teams and contribution to the agreed milestones of the CQUIN report. Invaluable support has been provided from the business intelligence analyst, IT team and clinical admin to deliver the aims of implementation.

Clinical Effectiveness Priority: Outcome Assessment Complexity Collaboration (OACC) (Patient Feedback)

CQUINN Standard: To improve the way we measure the impact of services on our patients,

families and carers


How was it identified as a priority?

Identification of the Breathlessness Clinic priority came via our Day Hospice team, who recognised breathlessness as a key symptom burden for many of our existing patients. They also recognised that we are currently not reaching many patients, including those with a primary diagnosis of respiratory disease, who could potentially benefit from expert symptom control, education and advice around self-management of breathlessness. The aim of the clinic, therefore, is to reach more patients with non- malignant disease, to create better integration/collaboration between primary and secondary care, introduce new and more precise pathways for referral and build on the symptom control provided within the Day Hospice therapeutic programme. The new service has been developed in collaboration with the acute hospital and community healthcare teams. It is confirmed that a Case Manager from Birmingham Community Health Care Trust will be involved in the programme most weeks. How was the Priority achieved? The clinic acted as a stand-alone service and can be extended to patients referred to other hospice services. The Hospices Multi-Disciplinary Team managed the clinic; however, it evolved, and we improved engagement with case managers, heart failure and respiratory teams in the future these teams will be more actively involved in delivering aspects of the programme. A Steering Group oversees the implementation of this new service. It will include a five-week programme (for one cohort of patients and carers per programme). There will be a maximum of 8 programmes run each year on Mondays from 13.00-15.30hrs.Referred Patients will come from existing Hospice services, Case Managers, Specialist Teams in the acute or primary care orGP's.

How was progress monitored and reported?

Patient Experience Priority: Breathlessness Clinic Standard: To reach and treat more patients with non-malignant disease within the West

Midlands region.


Regular steering groups were held, involving local specialist Clinicians from a multidisciplinary team. This included interdisciplinary teams such as Case Managers, Allied Healthcare Professionals (AHPs) (including those with a background in Pulmonary Rehabilitation), Palliative Care Clinical Nurse Specialists (CNSs), Specialist Palliative Care Social Workers and Medics. Existing evidence from the group and one-to-one interventions, recommended the Breathing, Thinking, Functioning (BTF) model as a foundation for Space to Breathe (Booth, 2013). This clinical model demonstrates the rationale for breathlessness in a wide variety of conditions and targets its treatment accordingly. Throughout the five sessions, Space to Breathe targets each element, in addition to weekly exercise sessions and group relaxation or mindfulness. Breathing – breathing techniques, physiology of breathlessness, Thinking – CBT model of addressing past experiences and anxiety, relaxation/mindfulness, Functioning – pacing techniques, managing energy, exercise Breathlessness is a complex symptom, Space to Breathe, therefore aims to include a wide variety of treatment interventions. These interventions are delivered by differing members of the multidisciplinary team, including AHPs and Clinical Nurse Specialists leading sessions on Medicines Management in addition to non-pharma logical management techniques and Crisis Planning.



2.2 Other notable achievements 2019 - 2020w

Children’s Services

The Children's Service has thrived, developed and expanded hugely over the past year. We now have 3 Children's Workers, 11 volunteers and 4 Bank Workers who provide emotional support to children and their families, both pre and post bereavement.

The service is into its third year of Children in Need funding, which has enabled the

support to be offered to the broader community. This includes running a peer support group, 'Growing Together', for children who have been bereaved by various means, not just a palliative illness. Close work with PR & Marketing and Fundraising has taken place to advertise this support to the communities of Birmingham and Sandwell, including the distribution of leaflets and written articles for HEM Life. Collaborative working and discussions with Marie Curie Solihull have also led to a plan of Birmingham St Mary's facilitating groups at their Hospice for children on the waiting list for support.

Also, the service worked closely with schools this year supporting staff with queries and

advice on how to manage situations such as a pupil facing a loss or going through a bereavement. An open day was held at the Hospice in November 2019 for school staff to learn more about the service and to register interest in working in partnership. Ongoing help from the service has taken place in the form of telephone support and by running training sessions at the schools themselves. The courses have received encouraging feedback and plans continue to be made to visit more schools throughout Birmingham and Sandwell to deliver the training.

In the run-up to Christmas 2019, the service ran a special memory event for the second year in a row for children and their families. This event allowed families to remember their loved ones together, find comfort in meeting others in a similar situation and to engage in therapeutic activities to help children to cope. This event will now take place yearly basis.

New memory-making activities have been introduced such as memory boxes, recordable bears and hand castings. General service information leaflets have been created in addition to the 'ground feels wobbly' to raise awareness of the Children's Service and the support it can offer. New resources have been purchased for the Children's Room, and exciting plans continue to be made to develop the service further.


First Contact

Started in the summer of 2019, clinical nurse specialists (CNS') in conjunction with triage nurse and Hospice at Home streamlined the first contact with patients' and families referred to BSMH. Referrals specify two days, five day or 10-day contact. All 2-day referrals are contacted on the same day as the referral. The change has been that now the five and 10-day referrals are contacted with 48 hours during the working week. If there is capacity at weekends, patients have been communicated with to confirm the referral has been received. At each first contact, the Patient is offered a clinic appointment at a location convenient to them. If unable to attend the clinic, then a home visit is provided at a suitable date.

Stepdown caseload

Over the summer of 2019, the Community team integrated further with Hospice at Home supporting the CNS' with caseload management. The CNs identified patients that needed continued support with their needs that the Hospice at Home nurses could help with home visits or telephone calls. At the same time, CNS' concentrated on the first assessment and those with complex symptom management.

Connect

New electric HR/Payroll system has been implemented and launched across the Hospice to enable and streamline processes and strengthen reporting around staff sickness, personal development review management and mandatory compliance.

Well Being

The Hospice recognises the importance of staff wellbeing, and how a workforce that is well and engaged will have a positive impact on the care, we can provide and outpatients. We have continued to progress with rolling out and embedding wellbeing initiatives. During the last year, we have; trained and launched 19 Mental Health First Aiders to support the wellbeing of staff across all areas of the Hospice. We run regular Menopause Cafes, which have been hugely successful and well attended, and have highlighted the link between mental health and menopause and enabled a much more supportive approach. We held a Wellbeing Day to coincide with Mental Health Awareness Week, delivering a range of activities, advice and resources and included financial advice sessions, seated body massage, mindfulness sessions, talks on body image, and food for mood awareness. We have also arranged a series of resilience workshops bespoke to the Hospice to give staff a range of tools they can access to help with their resilience.

Workforce Recognition


In line with our 40th-anniversary celebrations, a long service event took place to recognise our employees and volunteers with between 20 and 30 years' service. The event was an afternoon tea with Executive members present, and each attendee received flowers, certificate and gift. We held recognition events for our volunteers in June as part of the national Volunteers Week. The theme was Ruby Red in line with 40th-anniversary celebrations, and the activities included a buffet, quiz, guest speakers and a gift for all attendees.



2.3 Priorities for Improvements 2020 - 2021

How was it identified as a priority? Previously the management of incidents due to its paper-based form inherently lacked the governance process to ensure reporter's had useful feedback from incidents promptly. Due to the delayed reporting time, the reporter's required necessary feedback once an incident was reported and reviewed. 1The National Standards for Patient Safety Investigations’ looks to guide principles and standards for a local system based approach to patient safety investigations. The guiding principles for a local systems approach to patient safety investigations in NHS-funded care are: • Strategic • Preventative • Collaborative • Fair and Just • Expert/credible • People focused. With this mind, this allows the Hospice to embed a new practice around the management and approach towards patient safety incidents and additionally ensure feedback to incidents with the latest software features of Datix (electronic incident reporting system) are well embedded. Overall this will help the Hospice improve and implement a good reporting culture across the organisation. How will the Priority be achieved? With the implementation of Datix – electronic incident reporting system and a new Incident, Accident and Management Policy detailing the internal review around how incidents will be managed. Use of Datix will improve how an incident is primarily reported and ensure it is reviewed promptly allowing feedback to reporters in a timely manner. Moreover, the Hospice will take a proactive approach in reviewing the National Standards for Patient Safety Investigations and look to embed the guiding principles across the Hospice. In preparation for new National Standards for Patient Safety Investigations, the Hospice will have to undertake to develop the cultures, systems and behaviours necessary to respond to incidents in a way that ensures we learn from them and improve..

How was progress monitored and reported?

1 National Standards for Patient Safety Investigation – Guiding Principles and Standards March 2020

Patient Safety Priority: Clinical Governance Incident Management Standard: Improved Governance processes around the management of incidents and

ensuring feedback to incidents for staff are well embedded in practice


Quarter 1

Ratification of a new Incident, Accident and Management Policy that outlines good governance reporting requirements around feedback and patient involvement.

Ratification of new Duty of Candour Policy that outlines the importance of being open, honest and transparent and to include patients’ involvement in patient safety incidents.

Finalise the last stages of Datix, ensuring managers are trained on the system around the management of incidents requirements.

To update the clinical governance committee at meetings on progress, issues and risks Datix.

Quarter 2

Raise awareness and deliver presentations to relevant leads and clinical governance committee around the new Patient Incident Response Framework and highlight fundamental changes from the previous Serious Incident Framework 2015 coming in Spring 2022.

Deliver Clinical Governance mandatory training sessions to staff on how to report and receive feedback from incidents.

Monitor the transition of paper-based reporting to Datix Live Date of June 2020.

Quarter 3

Monitor incident feedback via Datix and ensure KPI is met around the management of incidents across the organisation

Lead on the development of Patient Safety Investigation Standards

Work closely with internal and external Complaint Leads to ensure triangulation of patient safety issues and investigations.

Develop Datix Feedback Reports to evidence reporters have timely feedback from incidents

Quarter 4

Ensure Patient Incident Response standards are reviewed, and any risks are mitigated to ensure assurance and oversight to the Board.

Maintain proper communication channels between the clinical teams to ensure continuous improvement across incident reporting, feedback and Patient safety investigations

Create detailed Datix reports for quantifiable identification of trends around incidents and lessons learned which will feed into the Quality report


How was it identified as a priority? The COVID- 19 pandemics have had a profound impact on how health care providers respond to the needs of patients affected by the virus and those with long term conditions who are at most risk. The hospices of Birmingham identified there would be an increase in demand on services for more of the population of Birmingham and Solihull and the need to provide coordinated support for the initiatives being delivered across the region.

It was also acknowledged that each Hospice has a limited resource to be able to meet the anticipated demand on services, aside from the expected loss to this workforce through sickness and long term self-isolation. It was agreed on a joint initiative across the hospices of Birmingham and Solihull would enable a city-wide response to the expected demand and in turn, provide a resilient solution for each Hospice for actual and expected workforce issues.

Birmingham and Solihull (BSoL)CCG has provided agreement for the joint initiative with the request for 24 hours/7-day services. How will the Priority be achieved? The Hospice will work with John Taylor Hospice (JTH) and Marie Curie in Solihull (MC) to establish a central call centre, currently based at JTH. It will be staffed by a specialist palliative care clinical team, including clinical nurse specialists, therapists, social workers, dedicated triage and clinical administrators to manage. The team will handle all new referrals, contacts from existing patients and families and health care professionals seeking advice and support. The service will be staffed by each Hospice with a smaller overnight team providing 24 hours/ 7 days support.

Clinical leads from each Hospice will be instrumental in creating an operational plan for HoBS, which is required at pace and to support the hospice teams in this new way of working. The Hospice at Home and community CNS teams will work as one extended team to provide support over the telephone and face to face care in patient's homes for symptom management, end of life personal care and verification of death.

Clinical Effectiveness Priority: A joint end of life response to COVID -19 pandemic Hospices of Birmingham

and Solihull (HoBs) Standard: To provide a coordinated 24 hour/7 day response service for Birmingham and

Solihull palliative patients to access hospice services and support. To reduce the use of inappropriate emergency calls, A&E attendances, and help enable the 2-hour discharge plans from acute care to home for the end of life patients. To provide support to our providers to help prevent a crisis in care in the community and broader access to hospice beds when appropriate.


How will progress be monitored and reported?

Quarter 1 The establishment of operational and oversight groups to provide the governance framework required for HoBS.

The clinical leads from the Hospice will participate and contribute to both the operational and oversight groups.

Joint working by clinical governance leads from the hospices will provide pathways to report risks, incidents and complaints associated with HoBS.

To update the clinical governance committee at meetings on progress, issues and risks.

To establish a joint SystmOne operational group to ensure activity through HoBS is captured for external reporting and assist with the evaluation of the service. To work with the differences within the systems and provide support for the user groups.

Develop and agree on mechanisms to capture patient feedback to contribute to the evaluation of the service. To be decided at the operational group with sign off at oversight group and confirm how this information is to be presented (a reference to quality priority 3).

Quarter 2 Contribute to the evaluation of the services (HoBS social/ HoBS therapy/ HoBS community) being provided and respond to changes following activity data or feedback from teams.

The provision of the overnight support component of HoBS will be reviewed, and the decision made regarding the future model will be agreed in conjunction with clinical leads from BCHC for the overnight response for the region.

Confirm and agree on the establishment of HoBS single point of access (SPA) for sustain partnership working across the city and in line with STP end of life priorities. Operational and oversight group to confirm workstreams for this pathway.

Develop and agree on pathways for social, therapy and community arms of HoBS

Quarter 3 Continue with agreed pathways within partner hospices.

Maintain excellent communication between the clinical teams with the cross-city working when required.

Continue to gather patient feedback at a local level and be ready to share with partner hospices.

Respond to the regional recovery plans in response to Covid-19 pandemic.

Quarter 4 Review the agreed pathways collectively with partner hospices. Understand what is working well and needs to remain and what needs to change.

Maintain proper communication channels between the clinical teams and provide cross-city working when required.

Continue to gather patient feedback at a local level and be ready to share with partner hospices.

Respond to the regional recovery/ sustainability plans in place for the pandemic/post-COVID-19

** There may be a requirement to amend or add in other mechanisms for how the progress of the joint response will be monitored and reported. Planning and implementation of HoBS are currently at an early phase, and work is based on the predicted demand anticipated across the city.


How was it identified as a priority? Hospices of Birmingham and Solihull (HoBS) is a new service which was developed rapidly as an immediate response to the COVID 19 pandemic. The existing community services from several Hospices were joined to allow patients, carers and other stakeholders to have a single point of access to flexible and coordinated supportively and palliative care services 24 hours a day seven days a week.

The use of Patient and carer experience is widely acknowledged in healthcare (NHS England 2018) as central to the provision of high-quality care. Seeking feedback from Patient and carers who have experience using HoBS is therefore vital to assure that HoBS is providing a service which accurately addresses the needs of those receiving care. The patient and carer experiences will be used as one component of a broader framework of measurement, which is being developed.

How will the Priority be achieved? Birmingham St Mary’s Hospice will work with John Taylor Hospice (JTH) and Marie Curie in Solihull (MC) to gather patient and carer feedback from those who have used HoBS services and to collect anonymised patient case studies identified by staff. There are a variety of ways that this feedback will be gathered. 1. Feedback on service provision shared across HOBS service gathered directly

from patients and carers, using:

a. Care opinion

b. Three values-based questions and space for free text to be added to patient

feedback forms

c. Identification of people willing to provide more detailed patient/carer stories by

and adding consent to contact for patient stories

2. Collection of anonymised patient case studies identified by HoBS staff

How will progress be monitored and reported?

Quarter 1 Develop and agree on mechanisms to capture patient feedback to contribute to the evaluation of the service. Agree at the operational group with sign off at oversight group and confirm how this information is to be presented.

Details of mechanisms to capture patient and carer feedback

Care Opinion accounts to be set up for each participating Hospice.

Establish a process to monitor and respond to the Patient, and carer feedback received

Clinical Effectiveness Priority: Gathering patient and carer feedback of a new service Hospices of

Birmingham and Solihull (HoBs) to ensure it addresses patients’ priorities and concerns

Standard: To provide multi-modal methods to collect meaningful Patient and carer

feedback about HoBS, which will be used to inform ongoing service evaluation and design. Proposed plans include self-report questionnaires, an online platform, and by telephone and are outlined in more details below.

To provide staff with guidance and templates to use in the collection of qualitative patient case studies. These case studies aim to demonstrate the "human impact” of HoBS and will be used for shared learning, celebrating successes and reflecting on ways things could be done differently.


Review of existing patient feedback forms to add free text section and questions relating to HoBS and including the addition of details about Care Opinion and seeking an indication of whether the respondents are willing to be contacted to share their stories in greater depth.

Develop, approve a standard “script” to be used to collect patient and carer experience stories over the telephone

Develop and implement the use of a standard collection tool and task via SystmOne for staff to identify patient/carer case studies

Quarter 2 Implement the use of Care Opinion to collect and respond to Patient and carer feedback

Collect patient and carer feedback using revised forms.

Establish a group of Patient and carers who are willing to share their stories in more detail and begin to gather their stories.

Continue to collect patient/carer case studies identified by staff.

Patient and carer experience data will be collated across HoBS hospices and discussed at the operational and learning will be feedback to teams at the HoBS huddle.

Patient and carer feedback information from HoBS will be presented and scrutinised at the Clinical Governance Committee.

Quarter 3 Continue to gather and respond to patient and carer feedback using Care Opinion.

Continue to collect patient and carer feedback using revised forms.

Continue to gather the stories directly from patients and carers.


To look for themes within patient and carer stories and feedback and use this information in service development and improvement.

Review the patient and carer feedback methods with partner hospices. Understand what is working well and needs to remain and what needs to change.

Patient and carer experience data will continue to be collated across HoBS hospices and discussed at the operational and oversight meetings. Learning will be feedback to teams at the HoBS huddle.

Patient and carer feedback information from HoBS will continue to be presented and scrutinised at the Clinical Governance Committee.

Quarter 4 Continue to gather and respond to patient and carer feedback using Care Opinion.

Continue to collect patient and carer feedback using revised forms.

Review the patient and carer feedback methods with partner hospices. Understand what is working well and needs to remain and what needs to change.

Continue to gather the stories of patients and carers who are willing to share their stories.


Patient and carer experience data will continue to be collated across HoBS hospices and discussed at the operational and oversight meetings. Learning will be feedback to teams at the HoBS huddle.

Patient and carer feedback information from HoBS will continue to be presented and scrutinised at the Clinical Governance Committee.

** As the planning and implementation of HoBS are currently at an early phase, there may be a requirement to amend or add in other mechanisms for how patient and carer experience will be monitored and reported.

The use of electronic feedback such as Care Opinion will allow the Hospice a potential interface for both users of our services and the wider population. It will


enable the Hospice to respond to the feedback which can be publically viewed, allowing stakeholders to see how the organisation responds, learns and makes changes based on their own experiences. The use of patient and carer stories will allow the Hospice to gain a greater depth of understanding of the lived experiences of people who use our services. These narratives will provide powerful tools for both reflections and allow greater understanding of the human impact our services have; in turn, this may lead to changes in the planning and running of our services. The collection of patient case studies will allow examination of the service from a clinicians’ point of view and may allow practicalities of service delivery to be addressed and reviewed. As the gathering of patient and carer experiences continues possible areas to consider for the future, alongside the methods outlined above, include:

Engagement with service users to review how patient and carer feedback is collected, collated and shared.

Developing a patient forum

The use of particular focus groups with a membership of patients, carers, volunteers, members of the wider community and staff for specific projects/service development.

We are extending the use of electronic feedback with the possibility of using the hospice website alongside other platforms.

Investigation of how the Hospice is viewed by those who have not used Hospice services and possible reasons why they have not used the Hospice.

NHS England (2018) Planning, assuring and delivering service change for patients. London



2.4 Statement of assurance from the Board

Review of services In 2018-20 Birmingham St Mary’s Hospice supported NHS commissioning priorities in Birmingham and Sandwell, providing specialist palliative care services. A brief outline of these services, funded through charitable giving, is provided below:

In-Patient Unit A mixture of single rooms with en-suite facilities and small multi-bedded bays for those needing intensive palliative and end of life care. Medical and nursing assessment is carried out daily, and there is access to medical advice 24 hours per day.

Community Palliative Care Team This team consists of Clinical Nurse Specialists, Doctors, Occupational Therapists and the Family and Carer Support staff who are experienced in palliative care and who provide support and advice to patients and carers in their own homes.

Satellite clinics Satellite clinics, based on GP practices, aim to reach more people across Birmingham and Sandwell by bringing care closer to home. The Clinics are by appointment and run by Clinical Nurse Specialists from the Community Palliative Care Team.

Day Hospice The Day Hospice holds several clinics during the week, which include a Therapeutic Programme, a clinically led educational programme focusing on living well with a life-limiting illness—a Clinical Nurse Specialist clinic weekly by appointment. A weekly volunteer-led Welcome Group provides social, and peers support for patients who have a life-limiting or terminal illness. This is a non-clinical service supported by a Senior Healthcare Assistant can see up to 20 patients per session.

Hospice at Home The Hospice at Home service, delivered by Registered Nurses and Health Care Assistants, provides patients with a palliative diagnosis care in their own home while nearing the end of life, or waiting for a package of care. Also, Hospice at Home offers an Urgent Response service for patients known to the Hospice. Coordinated by the duty Clinical Nurse Specialist, patients needing more urgent assessment or symptom management can be seen promptly.

Physiotherapy and Occupational therapy Exclusive agreements provide physiotherapy and occupational therapy services with University Hospital Birmingham NHS Foundation Trust. The


Therapists specialise in palliative care support and are designated to work at the Hospice with the clinical teams.

Complementary therapies Volunteers provide a range of complementary therapies managed and supervised by the Senior Physiotherapist through a Service Level Agreement with University Hospital Birmingham Foundation NHS Trust.

Family and Carer support services The Family & Carer Support Team provides specialist counselling, spiritual and psychosocial support to patients, carers and family members, including children whose parent is ill.

Bereavement Support Services At the Hospice, we consider bereavement support to be an essential part of quality palliative care. The Bereavement Support Service consists of highly skilled volunteers who have been trained in supporting people with grief and loss. They are managed by a full-time Senior Social Worker and receive one to one supervision from external counsellors paid for by the Hospice.

Birmingham St Mary’s Hospice: A research engaged and generating hospice We have continued to progress our research strategy during 2019-20. During 2019-2020 our research team have recruited to 3 research projects which are on the National Institute of Health Research (NIHR) portfolio. StOIC is the Study of Opioid-Induced Constipation, OPEL H@H is the Optimum End of Life care in Hospice at Home services, and PROSEC3 is a multi-centre evaluation of excessive saliva management in patients with motor neurone disease. The research adds value to care; our patients are generous with their time and dedication to research. We have recruited a Patient Research Ambassador to support our research agenda and advocate for patients and their carers. Our research champions, from a variety of clinical and support services, continue to help promote an understanding of the research conducted in the Hospice and the integration of research into day-to-day working practice. Our journal club continues, with both clinical and non-clinical staff attending, and many different individuals and grades of staff presenting papers. This forum allows the team to discuss the latest evidence and relate it to clinical practice. Articles discussed have been on varied subjects including moral distress; provision of palliative care in nursing homes; loneliness in cancer patients; hope; compassion; Nurse-led clinics and advanced clinical practice and the use of simulation and manikins in palliative care education. Birmingham St Mary's Hospice's research nurse became chair of the West Midlands Palliative Care Research Community in January 2020. This group shares experiences of and expertise regarding research and is attended by hospices,


academic institutions from across the region. The Clinical Research Network supports it. Other masters and PhD research projects are underway and being monitored by the research steering group, as reflected in their minutes. The research department also continues to support external researchers by circulating research surveys to staff on varied subjects, such as the Provision of Psychology services in palliative care; Patient support needs in COPD and Staff confidence the identification and assessment of mental health problems. Our staff continue to provide support and clinical supervision for students who are engaging in their research projects. Our staff have attended a variety of conferences. They have shared our expertise by presenting posters on a wide range of subjects including Understanding and Supporting Bosnian communities, Wellbeing for Staff in a Hospice Setting and Regional Collaboration Facilitates Delivery of Palliative Care research in West Midlands. Supporting Care Homes: what should end of Life care look like? Birmingham St Mary’s Hospice is proud of the research work it has, and continues to do, and is planning for research to be a core pillar of the hospice strategy from 2021 onwards.

Education: What we have done to educate our staff and other healthcare professionals During the period 2019 /2020, the Education Department appointed a new Clinical Education Lead. Upon this appointment, a period of re-evaluation of the education programme took place. Placements The Hospice continues to support Nursing, Medical and AHP placements, intending to increase placement capacity across all disciplines. We continue to support internships for Aston University Pharmacy students who undertake a foundation communication skills course. The medical student education programme/placement has been reviewed, and due to an expected increase in cohorts size, it was established to maintain an excellent standard of learning and work collaboratively with Marie Curie Hospice in the delivery of this training in 2020. Education Programme A new education programme has been redesigned with a balanced focus approached on aligning income generation and improving patient care and build expertise in our own staff and other organisations. The courses/ study days are being scoped and redesigned to meet the needs of our employees and our partners. A complete education programme for 2020/1 was due to be published at the end of March 2020. A revised model will now be released at the end of the COVID -19 Pandemic. During the pandemic is to focus on resources and delivery of education to professionals and communities to support COVID-19 end of life care. The Hospice has been commissioned to design and deliver a new Palliative Care Education programme in collaboration with Birmingham Community Healthcare Trust (BCHC) nurses. Although further evaluation is required, the initial feedback is positive and is likely to continue into the next year.


A further two members of staff completed the Sage & Thyme Facilitator course, and an additional four members of staff are expected to complete the Sage & Thyme facilitator course in 2020/1, to enable the education team to increase the delivery. After a period of evaluation of the Quality End of Life Care for All (QELCA), it concluded this method of training was not to be continued. The Hospice has been commissioned to deliver a bespoke EOL / Palliative care educational programme by NHS WOLVERHAMPTON CCG.

A relationship has been established with Sobell House to begin the delivery of two- day Enhanced Communication skills due for delivery in Oct 2020.

A fund was awarded for the delivery of Heart Failure & Palliative Care education. A Steering group was established working partners from Universities Hospitals Birmingham and the University of Birmingham. It was successfully coordinating design and delivery of a two-day CPD accredited conference which has been postponed due to COVID-19 until June 2021.

The Education Strategy 2018-2020, will be reviewed, and a delivery plan will align with the Hospice Strategy.

Guideline development and review The Hospice has developed a joint working forum with a partner (John Taylor Hospice), to look at national guidelines, decide on applicability to our care settings, review and provide recommendations for change in practice. A review of the following applicable National Institute for Health and Care Excellence (NICE) guidelines, guidance and standards has taken place during the year:

April 2019 NG86 NG112 KT114

Social Care Experience Recurrent UTI Catheter UTI

May 2019 NG114 COPD exacerbation

June 2019


QS179 NG122 QS17 CG104

Stroke and TIA Lung Cancer Lung Cancer Delirium

July 2019 QS184 QS187 QS101

Dementia Learning Disability Care and Support of people growing older Learning Disability behaviour that challenges

Sept 2019 QS183 NG131

Physical Activity Prostate Cancer

Oct 2019 QS187 QS101 NG115 NG 42 CG173 CG113 NG 89 QS189 NG138 NG139

LD Growing Older LD Challenging Behaviour COPD MND Neuropathic Pain Anxiety and panic VTE/DVT Suicide Prevention CAP Antimicrobials HAP Antimicrobials

Dec 2019 NG142 NG146 NG144 NG108 NG86 NG106 NG114 QS179 QS182 CG103 NG138 NG139 CG191

EOL Care for Adults Long Term Sickness Management Cannabis Product Decision Making and Mental Capacity Social Care Chronic Heart Failure COPD (Acute Exacerbation) Antimicrobial Prescribing Child Abuse and Neglect Peoples Experience of Adult Social Care Delirium Prevention Diagnosis and Management Pneumonia (Community-acquired) antimicrobial prescribing Pneumonia (Hospital-acquired) antimicrobial prescribing Pneumonia in adults diagnosis and management

Use of CQUIN payment framework 2019 – 2020 The second year of the CQUIN has been completed and a summary of the progress so far across the clinical teams has been captured in the Q4 report due for submission 30th April 2020. This includes recommendations to continue to improve the consistent use of the OACC measures in every care contact, the sharing good practice across teams and future evaluation through audit. A follow up shared learning event was also held as planned on 11th March 2020 for the hospices of Birmingham. This built on the success from the previous year and ensured that the ownership of the implementation of OACC remains with the clinical teams delivering patient care.

Data Quality Birmingham St Mary’s Hospice did not submit records during 2018-19 to the Secondary Users Service.


Information Governance Toolkit Information Governance is how we handle all organisational information, particularly personal and sensitive information about patients and employees. It allows organisations and individuals to ensure that personal information is dealt with confidentially, legally, securely, efficiently, effectively and ethically. The Hospice has updated its data protection framework in line with the General Data Protection Regulation. A new Privacy Policy has been released and available on the Hospice website, and several GDPR policies have been approved for use.

Birmingham St Mary's Hospice NHS Data Security and Protection Toolkit was submitted for assessment on 20 March 2020. All 56 mandatory evidence items were met.

Clinical Coding error rate Clinical coding is ‘the translation of medical terminology as written by the clinician to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format’ which is national and internationally recognised. We were not subject to the payment by results clinical coding audit during 2017-18 by the Audit Commission because we receive payment through block contracts.

Our Clinical Information Officer collects and collates data extracted from System ONE, our electronic patient record system, and a data integrity sub-group reviews this data monthly, analysing for themes and variance in expected performance.

Duty of Candour We have a newly devised Duty of Candour Policy, which describes and explains to all staff how to be fully compliant with Regulation 20. The Policy ensures that both a verbal and written apology is performed to people/patients using are service who have had attributed avoidable moderate/severe harm while using the Hospices' services. Additionally, all staff as part of their Mandatory Clinical Training will undertake Duty of Candour and elements of Clinical Governance training ensuring all clinical and non-clinical staff are aware of the regulation requirements.

As part of our Incident, Accident and Serious Incident Policy, it describes how the Hospice will ensure that we are open, honest, and involve patients in any problems they feel need addressing following our investigation. This provides our contractual requirements to include patient and family involvement and inevitably embed the Duty of Candour regulation requirement.


Part 3 – Review of quality of Performance

3.1 Clinical Data Birmingham St Mary’s Hospice uses ‘System ONE', an electronic patient records system which all patients are entered onto. We have chosen, therefore, to present data extracted from that SystemOne for the year 1 April 2019 to 31 March 2020 for the following services: Inpatient Unit (IPU)

There were 324 admissions to our IPU – this includes those patients that may have been admitted more than once

Community Palliative Care Team (CPCT)

This service accepted 1,044 referrals 15,050 patient contacts and 4,755 MDT & professional contacts were made during

the year

There were between 310 – 370 patients per month on the team's caseload during

the year

0

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Inpatient Unit Admissions 2019 / 20

020406080

100120140160

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Community Palliative Care Team Accepted Referrals 2019 / 20


Day Hospice

Overall attendance in our Day Hospice was 1,822. Day Hospice service was closed

on March 16th 2020 due to COVID - 19 Patients were unable to attend Day Hospice for a variety of reasons on 438

occasions (see the breakdown on the next page)

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Community Palliative Care Team Contacts 2019 / 20

Patient Contacts

MDT & Professional Contacts

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Day Hospice Attendance 2019 / 20

Therapeutic Programme

Welcome Group


Reasons for non-attendance – Day Hospice

Hospice at Home

This service accepted 358 referrals.

2,782 visits to patients were made during the year. The majority of which were attended by two Hospice at Home nurses.

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Hospice at Home Accepted Referrals 2019 / 20

Reason Total for 2019/20

Outpatient appointment 36

In hospital 87

In Hospice Inpatient Unit 19

Unwell 167

On holiday/away 16

Other (Visitors – family/district

nurse/friends/workmen/delivery)

39

Reason unknown 8

Cancelled by service 66



3.2 Quality Markers Patient Slip, Trips and Falls

Pressure Ulcers

Infection Prevention and Control

Medicines Management

Complaints and Compliments

Patients Slips, Trips and Falls All incidents involving Patient slip, trips and falls are monitored and reported through the Hospice’s incident reporting process and Hospice’s Quarterly Quality Report. Any serious incidents are reported to the Care Quality Commission via the statutory notification framework and to the relevant CCG for externally reportable requirement on to StEIS (Strategic Executive Information System)

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Hospice at Home - Visits 2019 / 20


During 2019/20 there was a decrease in the number of patients slips, trips and falls, with 43 reported compared to 70 reported during the previous year 2018/19. During the year three fall events met the criteria of a Serious Incident and were reported accordingly to the relevant Clinical Commissioning Group (CCG). A full comprehensive Root Cause Analysis (RCA) investigation was conducted for all three serious incident events identifying the lessons learned, avoidability of the cases and recommendations to stop the reoccurrence of similar incidents. Involving patient/family members in the RCA reports, addressing their concerns and performing Duty of Candour for each case is pivotal and was undertaken while ensuring compliance with Regulation 20 and being open, honest and transparent to our patients.

A Root Cause Analysis (RCA) is a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying cause and environmental context in which the incident happened. It is a collection of tools to help structure an investigation and analysis of events designed to get to the root of the problem. RCAs are routinely conducted when (but not exhaustive):

Attributed avoidable moderate/severe harm to a patient

If a patient has repeatedly fallen more than three times on current admission

If a patient suffers a loss of consciousness

When a fall results in an in-hospital assessment of admission

If a patient has abnormal neurological observations

If a patient were to die as the result of a fall or within 24 hours of a fall. Slip, trips and fall data is regularly monitored and used for educational purposes and safety awareness sessions.

Pressure Ulcers 2019/2020 saw a significant decrease in the number of patients who were admitted to the Hospice with Pressure Ulcers and Deep Tissue Injury (DTI). One hundred forty-three patients were admitted in 2019/20 with Pressure Ulcers/DTI compared to 219 in 2018/19.

0

2

4

6

8

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Severe Harm 1

Moderate Harm 1 2 1

Low Harm 1 4 1 1 1

No Harm 1 3 1 5 5 6 1 1 1 6

Falls ReportedApril 2019 - March 2020

No Harm Low Harm Moderate Harm Severe Harm


There has been a steady decrease in the number of patients admitted from home with a Pressure Ulcer/DTI with 46 patients admitted in 2019/20 compared to 57 in 2018/19. Patients admitted from hospital with a Pressure Ulcer/DTI stayed the same from the previous year reported with 43 admissions in 2019/20 equivalent to 43 in 2018/19.

To ensure appropriate and safe reporting of pressure sores and deep tissue injuries (DTI) with regards to the monitoring of grades and trends, our In-Patient Unit report all pressure ulcers and DTI for assurance purposes (On or during Admission) from either Hospital, Home or the Community. If we have identified whether the Pressure Ulcer has been identified (On admission), we ensure that this is communicated to the relevant Hospital/Care home to enable lessons learned for the transferring Hospital/Care Home team. With the development of Trends and appropriate category identification, the Hospice has a robust system in place to review all grades. It can identify further deterioration in skin condition, as well as determine whether they were avoidable or unavoidable. The information monitors the overall situation for the patients involved and offers learning and development opportunities to ensure the nursing practice is safe and individualised. A Registered Nurse on the In-Patient Unit is the nominated Link Nurse for Tissue Viability and ensures nursing staff have access to up to date training and provides practical assessment skills and advice to the IPU team. They also have contacts within the community and acute settings and feedback any concerns surrounding patients on admission or discharge with pressure ulcers or DTI. In further support staff in enhanced detection and prevention of the damage caused by pressure ulcers, the SSKIN tool is used. Early recognition of patients at risk of developing pressure ulcers is an essential part of the prevention care

Q1:April -June

Q2: July- Sept

Q3:Oct- Dec

Q4: Jan- March

Total:

Total Admissions with Pressure Ulcers 45 26 39 33 143

No. Admitted from Home with PU 12 13 11 10 46

No. Admitted from Hospital with PU 18 5 10 10 43

0

20

40

60

80

100

120

140

160

No. of Patients Admitted to IPU with Pressure UlcersApril 2019 - March 2020

Total Admissions with Pressure Ulcers No. Admitted from Home with PU No. Admitted from Hospital with PU


pathway. This supports heightened checking of patients’ skin and improved documentation. SSKIN is a five-step model for pressure ulcer prevention: NHS improvement (2017) recommends the use of SSKIN as the following: • Surface: make sure your patients have the right support. • Skin inspection: early inspection means early detection. Show patients and

carers what to look for.

• Keep your patients moving. • Incontinence/moisture: your patients need to be clean and dry. • Nutrition/hydration: help patients have the right diet and plenty of fluids

Medicines Management Medicines Management meetings are held quarterly, chaired by a Consultant in Palliative Medicine. A Pharmacist from a local Trust also attends these meetings. The Medicines Management Committee review all drug-related incidents and near misses as part of the Governance Framework. The Accountable Officer for Controlled Drugs at the Hospice is our Nursing Director and is a statutory role as outlined in the Controlled Drugs (Supervision of Management and Use) regulations 2013. The position requires the Accountable Officer to ensure the safe and secure management, as well as the use of Controlled Drugs. A deputy (Deputy Director of Nursing) has been appointed to cover this role when they are not in attendance at the Hospice. Birmingham St Mary’s Hospice is a partner organisation of the Birmingham, Solihull and Sandwell Local Intelligence Network for Controlled Drugs Governance. The network of organisations has agreed to a confidentiality agreement to share information in respect of the use, prescribing and management of Controlled Drugs. Meetings are held every quarter throughout the year. During 2019/20, the Hospice did not raise any concerns to the network. Clinical Pharmacy services are provided by the University Hospital Birmingham NHS Foundation Trust. The agreement includes the following provisions:

Pharmacist to visit the Hospice 3 days per week – 9 hours per week

Pharmacy Technician to visit the Hospice week day – 15 hours per week

Supply of stock drugs reviews storage quantities, expiry dates and storage conditions.

Monitor prescription charts and comprehensive medication reconciliation

Advice on medications to Patients, Doctors and Nurses

Operating a dispensing service on discharge During 2019-20 there have been 131 medication-related incidents of which 0 of these were externally related incidents where errors were made by others but identified by hospice staff.

Complaints and Compliments Complaints Summary – 01.04.19 – 31.03.20


All complaints are handled per our Policy and are thoroughly investigated, with a written summary of the findings provided to complainants and appropriate cascading of actions and learning to teams.

2019/2020

Total number of formal complaints 10

Nursing:

Clinical Education 0 Clinical Reception 0 Community Palliative Care Team (CPCT) 12 Day Hospice 0 Hospice at Home 0 Inpatient Unit (IPU) 0 Nursing Services 1

Medical:

Family and Carer Support Team (FACST) 1 Medical 23 Occupational Therapy 0 Physiotherapy 0 Support at Home 0

Income Generation and Marketing:

Community 0 Corporate 0 Events 0 Individual Giving 0 PR and Marketing 0 Retail 2 Supporter Services 34 Trusts and Grants 0

Support Services:

Administration and Governance 0 Facilities 1 Finance 25 Housekeeping 0 Human Resources 0 IT 0

Reception 0

Compliments and ‘Thank You’s’ The Hospice receives thank you cards and letters throughout the year. These are generally sent to individual departments. Compliments, thank you cards and letters are retained for a short period after they have been displayed in different departments. Particular phrases and expressions of gratitude are anonymised and reported in some Hospice documentation. Compliments are also received on

2 1 complaint related to CPCT and Medical 3 1 complaint related to CPCT and Medical 4 2 complaints related to Supporter Services and Finance 5 2 complaints related to Supporter Services and Finance


Patient and Carer feedback questionnaires.

The following are examples of some compliments received by both of these methods in 2019-20:

We will forever be thankful for the way you looked after our Mom…your lovely

attitude and the way you helped her in her final days will never be forgotten.

God bless you. (Card sent to IPU).

An enormous thank you to everyone for the outstanding care

and support you have shown to my mother during her stay with

you. I can't begin to say how deeply grateful I am to every one

of you for the respectful, dignified and exceptional ways in

which you cared for her. But most of all a huge Thank you for

your patience and support towards me and in particular for

taking the time to always answer the inordinate number of

questions I threw at you! (card sent to IPU)

All the staff are friendly & caring. Being here, I feel at peace. I get to see &

spend time with my loved ones while getting high-quality care. (IPU)

All staff at St Mary's are professional; empathic and caring. My father's quality

of life has improved since the transfer to St Mary's, and as a carer, I am

confident that he is receiving the best care possible. (IPU)

This service has been the first one, since Mom and dad first became ill, that I

have truly felt supported. (Community Team)

I feel that many issues I have had have been dealt with promptly by this

service. It isn't just supporting me but my wife too… This is an excellent

service. Thank you to everyone involved in my care. Excellent.

(Community Team)

You all listened. So crucial to someone who feels they have

become invisible. The amount of support I have been offered is

amazing … Tuesdays seem to be the only days I smile now.

(Day Hospice – Therapeutic Programme)

Overall, coming to St Mary's was the best decision I could have

made. It is a special place full of wonderful people. (Day

Hospice – Welcome Day)

Many thanks for all your help and kindness, all the advice and talks have

made me feel I can cope better when I am alone. It is wonderful to know

some people care, whatever age you are. (Breathlessness Clinic)

Trying to counsel a two and a half-year-old was always going to be difficult,

but (counsellor) was able to tailor her approach and empower me with the

skills to help him. He's now better able to express how he feels and as a

result is feeling much less anxious & angry. (Child Bereavement)

I am lovingly cared for, pampered even, by this bevvy of lovely ladies. All my

needs and wants are anticipated and provided for. They make a dying man

feel "almost" alive again. (Hospice at Home)

I am facing the hardest situation ever. The St Mary's Angels, that what I think

of them as, have given my wife and I so much support, without which I could

not have kept strong and seen it through to the end. From the first contact

with (named nurse), I was treated with respect, compassion and warmth. I

feel I have gained new friends. Thank you for everything Hospice at Home

girls. (Hospice at Home)

Part 3 – Review of quality of performance


3.3 Clinical Audit

As a provider of specialist palliative care, Birmingham St Mary's Hospice was not eligible to participate in any of the national clinical audits or national confidential enquiries. This is because of none of the 2019-20 audits or enquiries related to specialist palliative care. We do, however, have an extensive programme of internal clinical audit, which is an essential component of good clinical governance practices. Our focus is continually improving on the quality of life for patients and their families, ensuring a positive experience in a safe environment.

The regulatory assessment framework from the Care Quality Commission (CQC) is built around five key lines of enquiry (KLOE); is the service caring, safe, effective, responsive and well-led. Our audit teams oversee our audit programmes using national and local designed tools. This multidisciplinary approach includes dissemination of reports, monitoring action plans and re-audit where required.

Some of the outcomes from the audits reviewed during 2019-20 are detailed below and outline the Hospices commitment towards quality improvement.

CARING

What we were good at: Patient identified priorities are used as the basis of MDT meetings in Day Hospice, ensuring

the issues most important to patients are focused on Ensuring patients are involved in DNACPR conversations, where possible

What we are working to improve:

Ensuring that patient consent is documented before clinical photography

Ensuring that when capacity is assessed the results of this assessment are consistently recorded

SAFE

What we were good at: Risk assessments used in the prevention of falls and pressure ulcers and to inform care Appropriate prescription and use of anticipatory syringe drivers Ensuring our medications are recorded to encourage the safe delivery of care, particularly

where multiple professionals may be giving medication advice Infection Prevention and Control guidelines/policies and management systems outlined in

the Health and Social Care Act are adhered to Blood transfusions are administered in line with the Integrated Blood Transfusion Care

Pathway Medicines administered via the Patient Group Directive are done so within the guidelines

providing safe administration


Documentation of respiratory tract infections to ensure they are characterised into community-acquired, hospital-acquired, or aspiration pneumonia, or infective exacerbations of COPD, asthma or bronchiectasis

Documentation of frequency, indications for use and the maximum daily dose of PRN medications

Use of full patient ID including their DOB and address on prescription charts and TTOS


EFFECTIVE

What we were good at: Prescription of antibiotics reviewed appropriately and are informed by microbiology Controlled drugs are procured, recorded, administered and destroyed in line with expected

guidelines Capacity template used by members across the MDT Nutritional assessments are carried out on admission and reviewed if condition changes Mattresses and pillows regularly monitored to ensure they are fit for use


Improved consistency in the documentation of the indications for and instructions on when to start anticipatory syringe drivers

RESPONSIVE

What we were good at:

Bed rails patient information leaflet reviewed based on audit results

Initiated an audit on anticipatory syringe drivers as a response to the Gosport report

Where patients refuse to follow clinical advice for example around falls or pressure ulcer prevention, conversations take place explaining the risks and these conversations are appropriately documented

DNACPR decisions are communicated with relatives and to other healthcare providers on discharge


Improve antibiotic adherence and avoid prescription of broad-spectrum antibiotics by accurate documentation of respiratory tract infections by characterising them into community-acquired, hospital-acquired, or aspiration pneumonia, or infective exacerbations of COPD, asthma or bronchiectasis

Nutritional care plan being reviewed

Consistent use of International Dysphagia Diet Standardisation (IDDSI) when referring to altered textured diets.

WELL LED

What we were good at:

Reflecting on and learning from our practice for example ‘learning from deaths’ meetings

Sharing learning from audits, for instance, through a clinical newsletter "Learning from our

experience."


Process of audit approval by MDT

During 2019-20 Birmingham St Mary's Hospice held Audit Presentation meetings which covered audits on an art therapy project "Taking stock of 'Making Time' (arts for health and wellbeing)"; Urgent response and Anticipatory Syringe Driver.


Part 3 – Review of Quality of Performance

3.4 Feedback from patients and families on services

Patient and Carer feedback continues to be collected by way of questionnaires which are posted out to patients/carers with a stamped addressed envelope, or given out as part of information packs, at a pre-determined point in the service delivery for each clinical department. This is now a routine part of all hospice departments, and questionnaires are returned initially to service leads for potential action or follow up where necessary before the data is collated onto a spreadsheet and analysed.

As for last year, quarterly reports are produced for each hospice service from the data collected. These are then sent to the service Leads for their comments and to feedback to their teams. A summary of these reports is then collated into a single quarterly report. This includes the main statistics, a few examples of positive comments and issues that were mentioned, together with the responses to the latter from service leads. This report goes to the Nursing Director and a Clinical Governance Committee for assurance. An annual poster is also produced by the PR and Marketing Team displaying the leading statistics and examples of some of the responses (see next page). This is displayed around the Hospice for patients, visitors and staff to see. It can also be used with external stakeholders to showcase our patients and carers feedback.

These new questionnaires were first developed in 2016-17. The total number of returns for 2017-18 was 248. This year it is 401. Although this is higher than two years ago, it is slightly lower than last year, so work needs to be done to ensure that processes for distribution of the questionnaires are robust.

Work continues to be done to ensure any new hospice services have questionnaires developed appropriate to the service offered. Processes are in place to ensure all patients and carers are allowed to complete a questionnaire during or following episode of care with the Hospice.

.



3.5 Benchmarking Activity We have participated in the following benchmarking exercises: Hospice UK: Patient Safety (Inpatient Unit) Clinical Benchmarking Programme We have been participating in this programme now for five years. Approximately 100 hospices participate nationwide, and data is benchmarked per 1000 occupied bed days every quarter, focusing on the following three core patient safety metrics:

Pressure ulcers

Patient falls

Medication incidents Quarterly data is shared with the participants, with benchmarks established in categories by size of IPU (number of beds). These figures are also applied to an internal Quality Dashboard which includes data from all clinical services and is scrutinised quarterly by our Clinical Governance Committee. This enables us to identify any issues or trends in a timely fashion and act to determine the underlying causes. Birmingham St Mary's Hospice also takes part in Hospice UK benchmarking webinars with up to 40 participants from other hospices nationally, to ensure the validity of the data submitted and discuss any changes in the definition of metrics. Executive Clinical Leads in Hospice & Palliative Care (ECLiHP): West Midlands Regional Group Benchmarking Exercise Birmingham St Mary’s Hospice has continued to be part of the West Midlands Regional Forum of ECLiHP, which aims to establish a network for support, information exchange and learning. From within this group, 11 hospices take part in a benchmarking exercise which aims to highlight any quality issues in the region and to enable learning from good practice. The group meets quarterly. This year, the data collected was brought more in line with Hospice UK requirements and included the same categories of Pressure Ulcers, Falls and Medication incidents, plus additional data on:

Admissions.

Deaths and Discharges

Average Waterlow Scores (risk matrix for pressure ulcer development)

Infections Benchmarking for Diagnosis & Ethnicity Data on Diagnosis and Ethnicity has been routinely collected for several years. Mainly positive trends have been demonstrated, particularly for Diagnosis (Cancer vs Non-cancer), and we appear to be in line with other hospices for this indicator. However, after an extensive investigation, we were unable to find any suitable comparison data on Ethnicity in the age 18+ end of life general population in the geographical area we cover. However, an exercise was carried out looking at Ethnicity across the whole community of our geographic region, the results of which demonstrated ethnicity figures relatively representative of the local area.


Part 3 – Review of Quality of Performance

3.6 Statements on Birmingham St Mary’s Hospice Quality Account for

2019/20

Statement Requested From: NHS Birmingham and Solihull Clinical Commissioning Group

Statement from Birmingham and Solihull Clinical Commissioning Group

1.1 Birmingham and Solihull Clinical Commissioning Group (BSol CCG) as coordinating commissioner for Birmingham St Mary’s Hospice (BSMH) welcomes the opportunity to provide this statement for inclusion in the Hospice’s 2019/20 Quality Account.

1.2 A copy of the Quality Account was received by the CCG on the 21st September 2020 and the review has been undertaken in accordance with the Department of Health Guidance. This statement of assurance has been developed from the information provided by St Marys Hospice as well as specialist teams within BSOL CCG.

1.3 The information provided within this account presents a balanced report of the services that BSMH provide. The report identifies progress made over the last year against the three quality priorities for 2019/20. The report clearly outlines the quality priorities that have been set for 2020/21 and describes the actions that are needed to achieve these goals.

1.4 Commissioners are encouraged to see the extensive collaborative working with other providers, including close working with schools and supporting staff to manage bereavement. We note Quality Priority 2 for 2020/21: Joint End of Life Response to Covid- 19, and look forward to supporting the development and progress of this joint working for 20/21.

1.5 The CCG welcomes the appointment of the clinical lead for education and collaboration with BCHC nurses to deliver a new Palliative Care Education programme and look forward to the forthcoming evaluations following the positive feedback.

1.6 The continued reduction in the number of patients admitted to the hospice with pressure ulcers is acknowledged by the CCG who remain committed to working as a system to reduce all pressure ulcers.

1.7 Whilst it is pleasing to see the compliments that BSMH have received from patients and families, it would also have been helpful to have known whether the number of complaints had changed from last year.

1.8 Commissioners are assured by the continued focus on improving medicines management with BSMH participating in a clinical benchmarking programme focusing on core safety metrics and the identification of trends and themes and issues of medication incidents.

1.9 The CCG medicine management team acknowledge improvement in medication related incidents from last year and would find it helpful if BSMH could share further details of the steps taken to minimise the risk of the incidents reoccurring and how learning from incidents is shared across the organisation.


1.10 Commissioners acknowledge the positive feedback from the Care Quality Commission (CQC) unannounced inspection with the published report demonstrating an overall ‘Good’ and look forward to BSMH sharing details of any recommendations required and the actions set out to deliver them.

1.11 The Quality Account demonstrates a strong commitment by BSMH to education for their own staff and other health care professionals, including the workforce recognition for staff to celebrate their service with BSMH

1.12 As Commissioner’s we plan to work closer with BSHM over the coming year and we are committed to engaging with the service in an inclusive and innovative manner. We hope to continue to build close working relationships as we move forward into 2020/21

PAUL JENNINGS

Chief Executive Office


Part 3 – Review of quality of performance

3.7 Feedback and Comments

If you would like to provide feedback on the report or make any suggestions for content for future reports, please contact: Ameer Chughtai, Clinical Governance Manager Birmingham St Mary’s Hospice 176 Raddlebarn Road Selly Park Birmingham B29 7DA Tel: 0121 752 8739 Email: [email protected]

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